Domestic Partner Affidavit - Cedars

®
YOUR CHOICE
BENEFITS
DOMESTIC PARTNER BENEFITS
Cedars-Sinai offers benefits to our employees’ domestic partners. You may enroll your eligible domestic partner and their children for medical, dental and
voluntary vision benefits and for voluntary life insurance and voluntary accidental death & dismemberment insurance.
Domestic Partner Benefits Eligibility
Children Benefits Eligibility
Domestic partners are 2 adults (same or opposite sex) who
reside together, sharing their lives in an intimate and committed
relationship with a mutual obligation of support. For your
domestic partner to be eligible for benefits, you must either:
1 – Be legally registered as domestic partners, or
2 – Meet all of the following criteria:
You can cover children under age 26 who are your or your
domestic partner’s:
• Have been sharing a common residence* for at least
6 months and intend to do so indefinitely
• Are not related by blood to a degree of closeness that would
prohibit marriage
• Have assumed mutual responsibility for basic living expenses
• Are at least age 18 and capable of consenting to the
domestic partnership
• Are not married to anyone else or in a declared domestic
partnership with anyone else.
*Although you don’t have to show proof of common residence to enroll,
Anthem Blue Cross or MetLife may require it before paying claims.
Domestic partners do not include roommates, siblings, parents
or other similar relationships.
Any plan restrictions, provisions, coordination of benefits or
evidence of good health conditions in the Cedars-Sinai benefit
programs apply to domestic partner (and children) coverage in
the same manner as for all covered persons.
• Biological children
• Stepchildren (the children of your current domestic partner)
• Adopted children
• Children placed with you or your domestic partner for
adoption
• Children for whom you or your domestic partner are the legal
guardian or children a court has ordered you or your domestic
partner to cover under your healthcare plan (QMCSO).
In addition to meeting the eligibility requirements above,
children age 26 and older can be covered if:
• A doctor certifies in writing that they are incapable of getting
a self-supporting job because of a physical or mental condition
(and the certification is approved by the insurance company),
and
• They are unmarried and chiefly dependent on you or your
domestic partner for support and maintenance, and
• They have 6 months of creditable coverage or were already
covered under Cedars-Sinai benefits on their 26th birthday.
You must submit the doctor’s certification to the insurer/
benefit provider within 30 days of request (or a later deadline, if
provided by the insurance company). To continue coverage, you
may have to provide the doctor’s certification once a year.
BENEFIT QUESTIONS?
Ask the
HR/Employee Benefits Help Desk
Phone: 888-302-3941
Fax: 206-299-3158
Email: MBC.cshs@milliman.com
Web: Cedars-Sinai.MyBenefitChoice.com
Hours: Open Monday – Friday 6 AM to 5 PM PT
(Closed major holidays)
The MBC Service Center
YOUR
Domestic
CHOICE
Partner
BENEFITS – 09/2013
1
YOUR CHOICE
BENEFITS
Not Eligible for Coverage
You cannot enroll the following family members, even if they
otherwise meet the eligibility requirements:
• Other family members (parents, aunts, etc.) even if they are
legal dependents
• Foster children
• Family members in active service of the armed forces of any
country or subdivision of any country
• Stepchildren from a previous marriage, unless you or your
(current) domestic partner are their legal guardian or a court
order (QMCSO) requires you to cover them
• Grandchildren, unless you or your (current) domestic partner
are their legal guardian
• Family members living outside the United States (outside
the 50 states, the District of Columbia, the Commonwealth
of Puerto Rico, the US Virgin Islands, the Northern Mariana
Islands, Guam and American Samoa)
• Family members who are already covered – No double
coverage is allowed. If you, your domestic partner and/or
child work at Cedars-Sinai and enroll as an employee, you
cannot be enrolled as a dependent at the same time (or vice
versa); children can be enrolled as a dependent under only 1
parent’s coverage.
When You Can Enroll
Your Domestic Partner
You may enroll your domestic partner (and/or children) who meets
the eligibility requirements on page 1 (including living together for
at least 6 months):
• Within 30 days of being hired or first becoming eligible for
benefits (when you enroll yourself)
• During Annual Enrollment, held in May for benefits starting July 1
• Within 30 days of a qualified life event, such as receiving your
state domestic partnership registration or living together for
6 months and meeting the requirements for domestic partnership
(see page 1), your domestic partner involuntarily losing his or her
healthcare coverage or upon an eligible child joining your family.
Qualified life events are described in more detail in the Your
Choice Benefits booklet or in the Qualified Life Events brochure,
posted on Cedars-Sinai.MyBenefitChoice.com.
If you miss the enrollment deadline, you’ll have to wait until Annual
Enrollment (in May) to enroll for coverage starting July 1.
How to Enroll
New employees or during Annual Enrollment –
Enroll on the enrollment website: Cedars-Sinai.MyBenefitChoice.com
Qualified life event, including a new domestic partnership –
Contact the HR/Employee Benefits Help Desk (MBC Service Center) at
888-302-3941 or MBC.cshs@milliman.com
Documentation Required to Enroll
To cover your domestic partner (and/or children) under your benefits, you are required to provide evidence of their eligibility.
Documents accepted are listed below.
You have 30 days from the date you enroll to provide evidence of eligibility documentation to the HR/Employee Benefits Help Desk
(MBC Service Center). If not provided by the due date, your domestic partner’s (and/or children’s) coverage will not become effective
(or will be canceled).
DOMESTIC PARTNER
EVIDENCE OF ELIGIBILITY
CHILDREN
EVIDENCE OF ELIGIBILITY
Provide either:
In addition to the Domestic Partner’s Evidence of Eligibility, any
one of the following:
• Copy of state-issued domestic partnership registration/
certificate, or
• Cedars-Sinai Domestic Partnership Affidavit signed by you
and your domestic partner
and
• To enroll for medical benefits – Domestic partner’s Social
Security Number or Federal Tax ID Number (or complete
the Centers for Medicare & Medicaid Services’ opt-out
form).
2 Domestic Partner – 09/2013
• Copy of child’s birth certificate showing you or your domestic
partner as parent(s)
• Copy of child’s legal adoption paperwork or paperwork showing
child has been placed for adoption with you and/or your
domestic partner
• Copy of your previous year’s tax return; children don’t have to
be tax dependents to enroll, but if so, tax returns can be used as
evidence
• Copy of any Qualified Medical Child Support Order in effect
(see page 1).
Termination of Relationship
If your domestic partnership ends, your domestic partner and
his or her children are no longer eligible for coverage under the
Cedars-Sinai plans and their benefit coverage ends the last day of
the month your domestic partnership ends.
To cancel domestic partner coverage, you’ll need to provide
either of the following documents to the HR/Employee Benefits
Help Desk (MBC Service Center) within 30 days of the date the
domestic partnership ends:
• A state-issued termination of domestic partnership certificate,
or
• A completed Cedars-Sinai’s Affidavit of Termination of
Domestic Partnership form, which must be signed by both
you and your (former) domestic partner.
Your domestic partner (and children) will be eligible for 36 months
of COBRA continuation of medical, dental and voluntary vision
coverage if:
• They are covered under these plans when the domestic
partnership terminates, and
• Cedars-Sinai (or the MBC Service Center) is notified within
60 days of the domestic partnership termination.
Offering COBRA to domestic partners is not legally required –
but something Cedars-Sinai chooses to offer. Our COBRA administrator will send the COBRA forms to the last address on file with
the MBC Service Center. Please be sure to give the MBC Service
Center new addresses for you and/or your former partner.
Keep in mind that you are responsible for notifying the MBC
Service Center within 30 days of the partnership’s dissolution.
It is considered fraud to continue coverage after loss of eligibility
and the insurance companies could refuse to pay claims after
loss of eligibility, even if you’ve paid the premiums.
Need Forms?
The Cedars-Sinai Affidavit of Domestic Partnership and the
Termination of Domestic Partnership forms are available to download
and print from the Cedars-Sinai.MyBenefitChoice.com website
(on the left bar, click Benefit Booklets, then Forms, under
“Other Information”).
If you have questions or need assistance, contact our HR/Employee Benefits Help
Desk (the MBC Service Center) at 888-302-3941 or MBC.cshs@milliman.com.
Legal Issues
Before enrolling in domestic partner coverage through
Cedars-Sinai, you may wish to consult with an attorney about
the legal consequences of filing the Affidavit of Domestic
Partnership. If the domestic partnership ends, the Affidavit
may lead a court to treat the relationship as the equivalent of
marriage when establishing and dividing community property or
for ordering payment of support.
Marriage
You pay additional taxes on domestic partner benefits –
taxes that are not charged for spousal benefits. Don’t pay these
taxes if you don’t have to. If you and your domestic partner
marry, notify the MBC Service Center within 30 days of marriage
to change your marital status in your personnel record. If you
marry and don’t notify the MBC Service Center within 30 days of
marriage, you’ll have to continue to pay the additional taxes until
the next July 1. (See Tax Issues for a more detailed explanation.)
BENEFIT QUESTIONS?
Ask the
HR/Employee Benefits Help Desk
Phone: 888-302-3941
Fax: 206-299-3158
Email: MBC.cshs@milliman.com
Web: Cedars-Sinai.MyBenefitChoice.com
Hours: Open Monday – Friday 6 AM to 5 PM PT
(Closed major holidays)
The MBC Service Center
YOUR CHOICE BENEFITS 3
YOUR CHOICE
BENEFITS
Tax Issues
The IRS definition of “dependent” does not recognize domestic
partners, which has the following tax implication: the premium
that you and Cedars-Sinai pay for your domestic partner’s
coverage is considered taxable income. This is called “imputed
income.”
Imputed income is added to your paycheck to determine your
federal and state income and Social Security and Medicare taxes.
Cedars-Sinai is required to collect Social Security and Medicare
taxes from employees, and will withhold these taxes on this
imputed income.
Imputed income will not show as a line item on your paycheck.
You’ll see only the increase in your Social Security and Medicare
withholding.
Although Cedars-Sinai automatically withholds Social Security
and Medicare taxes on imputed income, it does not withhold
state or federal income taxes on imputed income. You may want
to have Cedars-Sinai withhold extra money for the federal and
state income taxes you will owe; you’ll need to complete IRS
W-4 and state withholding forms to change your tax withholding
amount(s). Download tax forms from the Cedars-Sinai intranet.
From the Administrative tab, click on the Human Resources
link, then the Forms link. Complete the forms and mail or fax
them to the Payroll Department:
Mail: Cedars-Sinai Medical Center
Attn: Payroll Department
8700 Beverly Blvd.
Los Angeles, CA 90048
Fax:
323-866-8833
Imputed Income Formula and Example
Mary is covering her domestic partner for medical coverage
under the HMO plan. Here’s how the imputed income is
calculated:
IMPUTED INCOME FORMULA
EXAMPLE
AMOUNTS
Total monthly premium for employee
plus domestic partner
$1,272.16
– Total monthly premium for employee only
- $578.25
= Monthly imputed income
= $693.91
x 7.65%* Social Security and Medicare tax
= Monthly amount withheld from your
paycheck for Social Security and Medicare
x 0.0765
= $53.08
*6.2% of pay (up to $114,000 in 2013) Social Security tax and 1.45% of pay
(under $200,000) Medicare tax. This example shows only the amount
of withholding attributable to the cost of a domestic partner’s medical
premium. Depending on tax filing status, if pay plus imputed income is more
than $150,000, the Medicare tax rate may be higher.
Mary owes taxes on an additional $693.91 of “income” for each
month her domestic partner is enrolled. The second paycheck
each month, Cedars-Sinai will add this additional income to
Mary’s taxable income and collect the FICA (Social Security and
Medicare) taxes.
Exception If Your Domestic Partner
Is a Tax Dependent
The imputed income requirement may not apply if your domestic
partner qualifies as your tax dependent. If you want to claim
your domestic partner as a tax dependent, please consult with
your tax advisor, and then notify the HR/Employee Benefits Help
Desk (the MBC Service Center). They will send you a Declaration
of Domestic Partner Tax Status to complete and return.
This is a summary of the Domestic Partner enrollment process meant to
accompany the Domestic Partner Affidavit. In case of discrepancies between
information presented here and the plan documents, the plan documents will
govern. Cedars-Sinai hopes to continue these plans indefinitely, but reserves
the right to amend, suspend, or terminate these plans in whole or in part any
time and for any reason, including the plan provisions as they are represented
in this summary.
4 Domestic Partner – 09/2013
AFFIDAVIT OF DOMESTIC PARTNERSHIP
 Declaration:
WE EACH SEPARATELY DECLARE, UNDER PENALTY OF PERJURY, UNDER THE LAWS OF THE STATE OF CALIFORNIA,
THAT THE STATEMENTS BELOW ARE TRUE AND CORRECT.
1.
That the partnership between:
and
Print or type name
Print or type name
commenced on or about: _________________________, 20 ___________.
(This date must be at least 6 months ago.)
That the above-named persons are either legally registered as domestic partners, or:
2.
That the above-named persons been sharing a common residence* for at least 6 months and intend to do so
indefinitely
3.
That the above-named persons are not related by blood to a degree of closeness that would prohibit
marriage
4.
That the above-named persons assumed mutual responsibility for basic living expenses
5.
6.
That the above-named persons are at least age 18 and capable of consenting to the domestic partnership
That the above-named persons are not married to anyone else or in a declared domestic partnership with
anyone else.
I understand that the total contribution for my domestic partner’s coverage is taxable to me as imputed income. The
nd
imputed income will be added to my 2 paycheck each month and result in Social Security and Medicare taxes being
withheld for that income. I understand I also owe state and federal income taxes on my imputed income. The imputed
income will be included on my W-2 at year end and will be included as part of my taxable income for state and federal
income tax calculation.

Employee’s signature and date
Print or type name and employee ID number

Domestic Partner’s signature and date

Return the completed form to:
Domestic Partnership Packet 2013-09
#602B
Print or type name
Cedars-Sinai
C/O MBC Service Center
P.O. Box 91109
Seattle, WA 98111-9209
AFFIDAVIT OF TERMINATION OF DOMESTIC PARTNERSHIP
 Declaration:
WE EACH SEPARATELY DECLARE, UNDER PENALTY OF PERJURY, UNDER THE LAWS OF THE STATE OF CALIFORNIA,
THAT THE STATEMENTS BELOW ARE TRUE AND CORRECT.
That the partnership between:
and
Print or type name
Print or type name
terminated on: _________________________, 20 ___________.
We understand that domestic partner (and children) healthcare coverage will end on the last day of the
month the domestic partnership terminates, as listed above when this form is returned within 30 days of the
date of termination. If the domestic partnership terminated more than 30 days ago, then domestic partner’s
(and children) coverage will end on the last day of the month in which this affidavit is returned. Premiums
paid when domestic partner (and/or children) was not eligible for coverage will not be reimbursed. We also
understand the domestic partner (and children) will be eligible for up to 36 months of extended medical,
dental and/or voluntary vision coverage on a self-pay basis through COBRA if: 1) They are covered under these
plans when the domestic partnership terminates and 2) Cedars-Sinai or the HR/Employee Benefits Help Desk
(MBC Service Center) is notified within 60 days of the domestic partnership termination.
EMPLOYEE:
at
Signed on (date)
(City and state where signed)

Employee’s Signature
Print or type name and employee ID number
DOMESTIC PARTNER:
at
Signed on (date)
(City and state where signed)

Domestic Partner’s Signature
More on back 
Domestic Partnership Packet 2013-09 #602C
Print or type name

Update addresses:
Employee’s new address:

Return the completed form to:
Domestic Partnership Packet 2013-09 #602C
Domestic partner’s new address (for COBRA notices):
Cedars-Sinai
C/O MBC Service Center
P.O. Box 91109
Seattle, WA 98111-9209